Tampa General Hospital



1536700-61046100PEDIATRIC FAMILY ADVISORY COUNCIL (pFAC)MEMBERSHIP APPLICATIONThank you for your interest in the Pediatric Family Advisory Council. Membership requires your successful completion of the registration process with Tampa General Hospital, including but not limited to: a health screening, which includes TB testing, a criminal background check, a formal interview process, and a mandatory orientation. All of your information will be treated as confidential.Please PRINT all information clearly.Name:Address: City/State/Zip Code:Telephone Number(s): Please indicate your preferred telephone number and the best time to reach you:Work: Home: Cell: i Email Address: Time preferred: AM: PM: Please indicate your willingness to share your contact information with other members: Yes NoPlease check all that apply: I am the Patient Spouse/significant other Caretaker OtherI have been treated at Tampa General Hospital since (year)Additional language(s) spoken: iPlease tell us which service(s) you/your loved one have used during the last two years:Please tell us which activities you might be interest in:Reviewing policies and proceduresImproving the experience for patients and their familiesDeveloping educational materialsImproving patient safetyOther projects/interests, please explain:Please tell us why you are interested in joining the Pediatric Family Advisory Council:Please describe any other committee experience you have had either at schools, in the community, through churches, etc.?Do you have experience with public speaking? Yes NoAre you comfortable speaking in a group setting? Yes No What are some things the staff did or said that made your experience at Tampa General Hospital more difficult?What are some things the staff did or said that made your family’s experience at Tampa General Hospital easier for you?What is the easiest way for you to participate in meetings? In Person Conference CallPlease return your application via email to: tzalduendo@ or mail to:Tampa General HospitalPatient Experience Office1 Tampa General CircleTampa, Florida 33606Thank you for taking the time to tell us about your interest in the Pediatric Family Advisory Council at Tampa General Hospital. ................
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